The Department of Health and Human Services Final Rule states that organ allocation shall not be based on the candidate's place of residence or place of listing, yet depending on where a child lives, his median waiting time for a deceased donor kidney transplant varies from 14-1313 days. Beyond individual factors, we do not understand why such wide geographic variation in pediatric kidney transplant access exists. The broad, long- term objective of this proposal is to move science forward by informing targeted interventions to reduce disparities in transplant access for children with end-stage renal disease (ESRD). This study will use novel geospatial analytical approaches to characterize the attributes of where children with ESRD live and where they seek transplantation, and we will gain insight into how these attributes interact to influence access to pediatric wait listing and transplant. Using an innovative ecological model which incorporates individual, community-level and institutional-level factors, we will disentangle the multiple factors which contribute to differental access to kidney transplant for children. For Aim 1, we will use robust national data to empirically derive a community-level health risk score for each patient's residential neighborhood and evaluate whether community-level health risk impacts transplant access. We hypothesize that children living in communities with less favorable social determinants of health will experience longer time from incident ESRD to wait listing and lower probability of transplant. For Aim 2, we will examine how community-level health risks interact with geospatial access to transplant for children with incident ESRD. We hypothesize that children living in lower-risk communities will have shorter time from incident ESRD to wait listing and increased probability of transplant, regardless of geospatial access to transplant centers; whereas for children living in higher-risk communities, less geospatial access to transplant will pose a significant barrier to wait listing and transplant. We will measure geospatial access using multiple metrics of the proximity of a patient's residence ZIP code to surrounding transplant centers, including travel distance and time. By examining the dynamic interplay of geography, community-level health and pediatric kidney transplant access, we will be able to identify how and where interventions should be implemented to reduce disparities. These results will inform the national discourse on how to improve quality, equity and access to care for all children. The NIH and NIDDK have emphasized the need for more rigorous research studies to 1) increase understanding of community influences on health behaviors and 2) to develop and test more effective interventions to reduce or eliminate health disparities.